Kids and Youth Registration — Central Presbyterian Church

Kids and Youth Registration Form

We are so excited to have your child(ren) join us for an upcoming Sunday morning or weekday activity! Please fill out the form below so we can know a bit more about them before they arrive.

Child's Name

First Name

Last Name

Birthday

YYYY

Grade in School

School Attending

Name of Primary Guardian

First Name

Last Name

Phone Number of Primary Guardian

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Way to Contact You

Phone Call

Text Message

Facebook

Post Mail

Names and relationship to child of others able to pick-up your child.

Allergies

Please write none if child does not have allergies

Other heath conditions or learning differences (will only be shared with staff and supervising adults who care for your child)

For emergencies medical reasons my student carries

Epi Pen

Rescue Inhaler

Glucose/ Insulin

Other

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Emergency Contact's relationship to child

Participation Consent/ Permission

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the children and youth ministries of Central Presbyterian Church. I/We understand that there are inherent risks involved in any ministry or related event, and I/we hereby release Central Presbyterian Church, its Pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Central Presbyterian Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided on the following page is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

Date of Permission/ Participation Consent

YYYY

Image/ Photo Consent

I understand that photos/ video may be taken of my child during this activity. I agree that any pictures of my child taken at the activity may be included, without identifying information, in brochures and posters for promotional purposes. I also give consent for pictures of my child to be posted on the church web site and Facebook pages. *Central Presbyterian Church will abide by our Safe Church policy when posting pictures of minors.

Date of Image/ Photo Consent

YYYY